PATHWAYS FOR YOUNG LEADERS REGISTRATION APPLICATION SEPTEMBER 2019 – MAY 2020
APPLICANTS FIRST NAME
LAST NAME
APPLICANTS D.O.B.
AGE
GRADE
PARENT/GUARDIAN
STREET ADDRESS
APT #
CITY
STATE
ZIP CODE
PARENT/GUARDIAN CELL#
EMAIL ADDRESS
DOES CHILD HAVE ANY FOOD ALLERGIES
IS CHILD IN GOOD HEALTH
TAKING ANY PRESCRIBED MEDS
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IF YES PLEASE LIST ALL MEDICATIONS
EMERGENCY CONTACT NAME
EMERGENCY CONTACT CELL #
CHILD HAS PERMISSION TO WALK HOME ALONE AT 5:30 PM DISMISSAL
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